Milligan Tiffany, Smolenski Derek, Lara-Ruiz Jose, Kelber Marija S
Psychological Health Center of Excellence, Defense Health Agency, Falls Church, Virginia.
JAMA Psychiatry. 2025 May 21. doi: 10.1001/jamapsychiatry.2025.0695.
IMPORTANCE: In recent decades, evidence-based psychotherapies to treat posttraumatic stress disorder (PTSD) have been developed with robust evidence bases. However, efficacy observed in clinical trials is not always directly applicable to clinical practice. OBJECTIVE: To estimate the percentage of patients in both military and veteran (hereafter milvet) and nonmilvet populations that lose their PTSD diagnosis after treatment. DATA SOURCES: We used the PTSD Repository to identify studies with adults with a DSM-IV/DSM-5 PTSD diagnosis based on a validated assessment. The repository, maintained by the US National Center for PTSD, is continually updated with randomized clinical trials and includes studies published from January 1988 on. STUDY SELECTION: For eligibility, PTSD had to be the primary treatment target, with psychotherapy applied as monotreatment. Eligible studies reported the number of participants who did not meet diagnostic criteria for PTSD posttreatment. When this review was initiated (October 2023), the repository contained 496 unique studies. Data analysis was completed from October 2023 to June 2024. DATA EXTRACTION AND SYNTHESIS: The repository follows Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines and uses Cochrane Risk of Bias 2.0. We used mixed-effects logistic regression models to estimate diagnosis loss and incorporated milvet status and sex as covariates. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of participants who no longer met criteria for a diagnosis of PTSD posttreatment as assessed by a validated instrument. RESULTS: We included 34 randomized clinical trials (N = 3208 participants). Point estimates of diagnosis loss across trauma-focused treatments for nonmilvet samples ranged from 65% to 86%. Milvet samples had lower proportions of diagnosis loss in studies of cognitive processing therapy and prolonged exposure compared to nonmilvet samples, ranging from 44% to 50%. There was substantial overlap between the covariates of milvet status and sex. An exploratory analysis identified eye movement desensitization and reprocessing as having the highest proportion of diagnosis loss, but there was substantial heterogeneity, and none of the studies were milvet-focused or conducted in the US. Also, 95% confidence intervals partially overlapped for all trauma-focused treatment estimates. CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis contributes to the substantial literature on psychotherapeutic treatments for PTSD by meta-analyzing the probabilities of diagnosis loss for each psychotherapy. Diagnosis loss data are a relatively straightforward way to discuss potential benefits when initiating a therapy or when discussing potential barriers to progress in treatment.
重要性:近几十年来,已开发出具有充分证据基础的循证心理疗法来治疗创伤后应激障碍(PTSD)。然而,临床试验中观察到的疗效并不总是直接适用于临床实践。 目的:估计军人和退伍军人(以下简称军退人员)以及非军退人员群体中治疗后不再符合PTSD诊断标准的患者百分比。 数据来源:我们使用PTSD资料库来识别基于有效评估确诊为DSM-IV/DSM-5 PTSD的成人研究。该资料库由美国国家PTSD中心维护,通过随机临床试验不断更新,包括1988年1月以来发表的研究。 研究选择:为符合条件,PTSD必须是主要治疗目标,心理治疗作为单一治疗方法应用。符合条件的研究报告了治疗后不符合PTSD诊断标准的参与者数量。在本次综述启动时(2023年10月),该资料库包含496项独特研究。数据分析于2023年10月至2024年6月完成。 数据提取与综合:该资料库遵循系统评价和Meta分析的首选报告项目(PRISMA)报告指南,并使用Cochrane偏倚风险2.0。我们使用混合效应逻辑回归模型来估计诊断消除情况,并将军退人员状态和性别作为协变量纳入。 主要结局与测量指标:主要结局是经有效工具评估,治疗后不再符合PTSD诊断标准的参与者比例。 结果:我们纳入了34项随机临床试验(N = 3208名参与者)。非军退样本中,针对创伤聚焦治疗的诊断消除点估计值范围为65%至86%。在认知加工疗法和延长暴露疗法的研究中,军退样本的诊断消除比例低于非军退样本,范围为44%至50%。军退人员状态和性别的协变量之间存在大量重叠。一项探索性分析发现,眼动脱敏再处理疗法的诊断消除比例最高,但存在很大异质性,且没有一项研究以军退人员为重点或在美国进行。此外,所有创伤聚焦治疗估计值的95%置信区间部分重叠。 结论与意义:本系统评价和Meta分析通过对每种心理治疗的诊断消除概率进行Meta分析,为关于PTSD心理治疗的大量文献做出了贡献。诊断消除数据是在开始治疗时或讨论治疗进展的潜在障碍时讨论潜在益处的一种相对直接的方式。
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